Phyllis Berger introduces a completely new approach to chronic pain for physiotherapists

Non-Interventional Pulsed Radio Frequency (PRF)

Physiotherapy and indeed the medical profession have failed many chronic pain patients!

There are so many patients that are on anti-epileptics, anti-depressants and or analgesics even duragesic patches and yet they remain in pain. These medications may alleviate pain, improve pain management or have little to no effect on the pain in some patients. There are also side effects that are so intolerable to many patients that they have to stop taking these medications and there are some patients that are so angry because there seems to be nothing that helps their particular pain.

Physiotherapy regimens world-wide encourage various approaches for chronic pain as often it is very difficult to find a solution for these patients.

These are:

explaining pain, communicating with the patient in such a manner that we reverse the cognition that the patient engages in when in severe pain, teaching coping skills, learning acceptance of the pain, improving body conditioning, improving posture, teaching skills in relaxation, visualization and breathing, mirror therapy – it goes on and on and yet some patients keep comingback for “another” appointment and the physiotherapist may wonder what she/he can do next!

Some patients do respond to TENS (transcutaneous electrical nerve stimulation) – in fact we encourage patients to improve their quality of life and to resume their occupational and their recreational activities while using the TENS. TENS may relieve some patients (the responders) and others will have little to nil response.

Psychotherapy is also advocated and hypnosis has been known to help many patients.

ALL of the above treatments are valuable and may provide relief in some patients but this usually takes time, puts strain on the patient’s budget and reduces their medical aid ‘basket’.

New generation

A new generation of electrical current has now been developed and it is “proudly South African”. The history of this treatment is interesting as it provides an insight into the methodology of the device. Anesthetists routinely use mapping devices to search and or identify usually the peripheral nerve that is responsible for the pain prior to lidocaine injection to block nerve conduction and produce pain relief. It was found that this nerve mapping procedure if placed on the nerve for 5mins could also improve pain. A prototype of the NMS 460 was developed that permitted 80 kHz of pulsed radio frequency current to be delivered by a probe to the painful nerve and amazing results were observed in both pain relief and rehabilitation of muscles.

A pilot study was embarked upon by researchers, Goroszeniuk and Kothari (2009) at a large Pain Management Centre at St Thomas’ Hospital in the United Kingdom. The treatment was applied to 35 eligible patients suffering with intractable peripheral neuropathic pain.

The results were unequivocal – in 19 patients the Visual Analogue Scale (VAS) was reduced to 0/10 (100% improvement). In the remaining patients the results were as follows:

4 patients VAS = 90% improvement

4 patients VAS = 63% improvement

4 patients VAS = 50% improvement

Last 3 cases, 25%, 20%, 15% respectively.

The fact that the patients selected for the above study had excellent results is remarkable, as these patients had experienced intractable pain that had previously not responded to other therapies. In most studies if there is between 30 – 50% improvement in pain, it is considered a worthy treatment. In the above situation to have a little more than half the patients experiencing 100% improvement, the NMS therapy could be considered a breakthrough treatment.

My experience

My introduction to this device was through the Witwatersrand Pain Clinic and it was suggested that I should evaluate this device to assist in the management of chronic pain patients.

I then had the opportunity to work with both the prototype and the newly developed NMS 460 for two years and have observed phenomenal changes in pain and movement in various types of conditions – varying from neuropathic pain from different aetiologies, nociceptive conditions to neuropraxia such as in Bell’s palsy.

The NMS current waveform is a combination of low frequency and a square wave with a superimposed pulsed radiofrequency that has an exponential decay. This then provides a low frequency (1, 2, 5 or 10Hz) that produces endorphins, a square wave that produces a direct current with bioelectric effects (width of 0.1 or 0.2ms) and then the superimposed PRF that is too fast for bioelectric effects and has a bioelectronic effect with a magnetic field that purportedly passes to the dorsal root ganglion. The latter effect will block pain at central levels and may change gene expression enabling the damaged cells to change and assist the nerve to regenerate.

It has been observed that only 4 – 5 treatments to the facial nerve in acute Bell’s palsy are necessary to improve all the sequelae and the function of this condition instead of at least 2 weeks and then possibly up to 3 months. In a recalcitrant patient with Bell’s palsy of 6 months duration, one month of daily home treatment of 5mins on the facial nerve branches produced changes in the Oxford muscle grading from 0/5 to – 3-4/5 according to DA Muller (2010).

In patients with neuropathic symptoms of burning, sharp, twinging, electrical shock type of pain, paraesthesia, dysaesthesia and or allodynia – all symptoms are usually dissipated in 3 treatments! This result may last in perpetuity or return many months later but much reduced and the condition can then be resolved more easily with even less treatment. This enables the physiotherapist to get on and continue with the normal treatment to rehabilitation.

Great potential

Dramatic changes have been observed in many other musculoskeletal conditions and it appears that the process of activation of the nerve in a defunct area will

Improve nerve conduction, muscle strength and pain relief. We all acknowledge that pain decreases muscle strength and a vicious cycle of pain leads to muscle weakness and more pain. For the first time we are seeing muscle rehabilitation and pain relief occurring concurrently and speedily!

Invasive pulsed radio frequency is not the domain of physiotherapists – it also does not always relieve the condition, may have to be repeated and often causes trauma during the procedure such as bruising and scarring – whereas non-invasive pulsed radio frequency is perfectly positioned for use by physiotherapists. It is not painful, does no harm or damage, may have remarkable results in previously intractable pain and the physiotherapist has the knowledge of anatomy to target the nerve supply involved in the condition. The most dramatic effect of this treatment is that only 3 treatments are required to clear neuropathic symptomatology in most patients and we can virtually promise this result to our patients.

The only negative aspect of this treatment is that it does not help every patient – I assume this is because we often have a combination of neuropathic, nociceptive and or neurogenic pain states in a patients’ condition.

There are currently 15 therapists in Johannesburg and 10 abroad that are now using this device that have had surprising results and have corroborated my own results. Pilot studies and randomized controlled trials are now in progress.

This current is an innovative shift in our armamentarium used to treat patients and I would urge physiotherapists to consider this treatment as a first line of defense in most treatments.

Phyllis Berger BIO

Phyllis Berger is a physiotherapist and acupuncturist with a special interest in electrical currents in relation to the treatment of pain. Phyllis realized that certain types of electrical current relieve various conditions and symptoms related to either acute and or chronic pain.

Her clinical experience in pain management commenced in 1994 working at the Rand Multidisciplinary Pain Clinic. She has attended many international pain conferences, published many articles (http://www.easemypains.co.za/articles.html)and four books on pain management and has lectured on this subject both nationally and internationally.

Phyllis continues to evaluate advances in electrical pain management and is presently involved in research on this subject in her Pain Management Practice situated in Johannesburg.